Provider Demographics
NPI:1588061527
Name:VLASOV, KONSTANTIN
Entity type:Individual
Prefix:
First Name:KONSTANTIN
Middle Name:
Last Name:VLASOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 S HAYFORD RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99224-7023
Mailing Address - Country:US
Mailing Address - Phone:509-459-0614
Mailing Address - Fax:
Practice Address - Street 1:1221 S HAYFORD RD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99224-7023
Practice Address - Country:US
Practice Address - Phone:509-459-0614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60217077183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist